ACUTEABDOMEN

1emss17.sats-kbh.dk

EMSS17:AcuteAbdomencoursematerialIntroductionDuringtheacuteabdomenworkshopattheEmergencyMedicineSummerSchool2017(EMSS17)youwilllearnhowtoassessandtreatpatientspresentingwithacuteabdomen(abdominalpain).There'saninexhaustiblenumberofreasonswhypatientspresentwithacuteabdomen.In35%ofthecaseswewillneverfindthereasonforthesymptoms.Becauseofthegreatamountofdiagnoses,wewillgiveyousometoolstodiagnosethepatientwithacuteabdomen.Anoverviewofthemostcommonandmostdangerousreasonsforacuteabdomenisgivenintheendofthisdocument.Mostdiagnosescausingacuteabdomencanleadtolife-threateningdiseasesifleftuntreated.Perforationswillleadtocontaminationoftheabdomencausingsepsis,multi-organfailureanddeath.Severeabdominalbleedingcanlikewiseleadtodeathinashorttime.

AssessmentofthepatientwithacuteabdomenPatientspresentingwithacuteabdomenshouldbeinitiallyassessedusingtheABCDEassessmentapproach.InthismaterialwewillnotgointodetailswiththeABCDEassessment,butrefertothecoursematerial'ABCDEWorkshop'thatyou'llfindonhttp://emss17.sats-kbh.dk/course-materials.Howyouexaminetheabdomenisdescribedinthevideothatyou'llfindintheonlinecoursematerialsforthe'AcuteAbdomenWorkshop'.Inwomenwithacuteabdomenremembertoconsidergynaecologicconditions.Ingeneral,whenawomanpresentswithacuteabdomenaurineorplasmahCGshouldbemeasured(toassessifthepatientispregnant)andagynaecologicalexaminationshouldbeconsidered.

ACUTEABDOMEN

2emss17.sats-kbh.dk

GettingclosertothediagnosisandassessingpainItcanbedifficulttodiagnoseapatientwithacuteabdomen.Itisimportanttousethemedicalhistoryasadiagnostictool.Tohelpyouremembertherelevantquestionsregardingabdominalpainyoucanusethe'OPQRST'assessmenttosystematicallyassesspain.TheOPQRSTpocketguideisshownbelow:

LocationofthepainThelocationofabdominalpaincanbedescribedusingdifferentabdominalregions.Dividingtheabdomeninregionscanbedonedifferently.Inthisworkshopwewillusetheninequadrantsshowninthefigurebelow.Thisapproachisalsoshowninthevideoonthecoursematerialswebpage.Themostcommonconditionsarelistedwithrespecttothequadrantwherepainmostoftenpresents.Thislistisnotcomprehensiveandthelocationofthepaincanvarywidelyandacrossregions!

ACUTEABDOMEN

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Righthypochondriacregion:-Cholecystitis-Biliarycolic-Cholangitis-Basalpneumonia

Epigastricregion:-Pepticulcer-Pancreatitis-Rupturedaorticaneurism-Acutecoronarysyndrome/acutemyocardialinfarction

Lefthypochondriacregion:-Spleenicrupture-Basalpneumonia

Rightlumbarregion:-Pyelonephritis-Kidneystone

Umbilicalregion:-Appendicitis-Rupturedaorticaneurism

Leftlumbarregion:-Diverticulitis-Pyelonephritis-Kidneystone

Rightiliacregion:-Appendicitis-Ectopicpregnancy-Ovariantorsion

Hypogastricregion:-Cystitis

Leftiliacregion:-Diverticulitis-Ectopicpregnancy-Ovariantorsion

Diffuseabdominalpain:-Perforationofanorganandperitonitis-Intestinalischemia-Adrenalcrisis-Bowelobstruction

ACUTEABDOMEN

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PreparingthepatientforsurgeryThePreparingForSurgerypocketguideshownbelowshouldservesasaguideforthethingsyoushouldremembertoconsiderwhenpreparingapatientforsurgery.Remember,ifapatientneedsemergencysurgeryyoushouldimmediatelyseekexperthelpandnotletanyunnecessaryactionsdelaythepatient’swaytosurgery!

ACUTEABDOMEN

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Acuteabdomen:diagnosesWewillnowgothroughsomeofthemostfrequentorlife-threateningcausesofacuteabdomen:

- Appendicitis- Perforatedulcer- Acutebiliarydiseases:

o Gallstoneattacko Cholecystitiso Cholangitis

- Bowelobstruction- Acutepancreatitis- Urinarytractstones- Rupturedabdominalaorticaneurism- Gynecologiccausesoftheacuteabdomen

ACUTEABDOMEN

6emss17.sats-kbh.dk

AppendicitisThemostfrequentreasonforacuteabdomen.Itisseeninallages,butismorefrequentamong10-30yearolds.Theconditioniscausedbyaninflammationintheappendix.Theconditioncanvaryfromamildlocalinflammationtoaperforatedappendixwithdiffuseperitonitisandsepsis,whichisalife-threateningcondition.

SymptomsOPQRST:Increasingabdominalpaindevelopingin12-24hours,mostoftenlocatedtotherightiliacregion.Paincanbeworsenedbymovement.In50%ofthecasesthepainstartsasdullandachingintheumbilicalregionandprogressestomoresevereandconstantpainintherightiliacregion.Nauseaisoftenpresentandvomitingandfevercanbeseen.

ClinicalpresentationThepatientpresentswithpainandliesstillinbed.Palpationshowssorenessintherightiliacregion.Peritonealreactionorabdominalguarding(“défensemusculaire”)canbeseen.Vitalsigns:temperatureof37.5-38.5°C,tachycardia(highpulse).

FurtherinvestigationBloodtests:↑C-reactiveprotein(CRP)and↑leucocytescanbeseen.Considerultrasound.

DiagnosisAppendicitisisaclinicaldiagnosis.AbdominalCTorultrasoundcanverifythediagnosiswithasensitivityof90%.Normallythediagnosisisfinallyverifiedduringsurgery.

TreatmentStrongsuspicionofappendicitis:Preparethepatientforsurgery.Diagnosticlaparoscopyandremovaloftheappendix.Ifperforatedappendix:IVantibioticsaccordingtolocalguidelines.Littlesuspicionofappendicitis:admissiontosurgicaldepartmentfollowedbyclinicalexaminationagainafter6-8hours.

ACUTEABDOMEN

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PerforatedulcerAperforatedulcercanbelocalizedinthestomachortheduodenum.Theconditionismostcommonlycausedbyacid,medications(e.g.NSAIDs)and/orthebacteriaHelicobacterpylori.Itismostcommonlyseeninpatients>50yearsold.Oftenagastricorduodenalulcerdoesnotcauseseveresymptomspriortoperforation.Nightlyburningordullpainintheepigastricregioncanbeexperiencedaswellasanorexia,vomitingandweightloss.

SymptomsOPQRST:suddenonsetofseverepainintheepigastricregionthatincreaseswithmovement.Nauseaandvomitingismostoftenseen.Thepatientisoftenknownwithpepticulcers.

ClinicalpresentationAcutelyaffectedpatient,paleandlyingstillinbed.Severepainwhenpalpatingtheabdomen,mostoftenabdominalguarding.Vitalparameters:superficialrespirationduetopain.Tachycardia(highpulse).Hypotension(lowbloodpressure)ifseptic.

FurtherinvestigationsBloodtests:↑CRPand↑leucocytesABGCToftheabdomen(unlessabdominalguarding,thenCTmustnotdelaysurgery)orabdominalX-rayECG

DiagnosisMedicalhistory,clinicalpresentationandCTwithfreeintraabdominalairconfirmsthediagnosis.Thediagnosisisfinallyconfirmedduringsurgery.

TreatmentPreparethepatientforsurgery.Laparoscopicsuturingoftheperforation.Aftersurgery:eradicationofHelicobactorpyloriandprotonpumpinhibitors(medicationtodecreaseacidproductioninthestomach)untiltheulcerhashealed.

ACUTEABDOMEN

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AcutebiliarydiseasesTherearethreecommonconditionsofthebiliarysystemthatcauseacuteabdomen:gallstoneattack,cholecystitisandcholangitis.GallstoneattackAsimplegallstoneattackcanbeseenintheemergencydepartment,butismostlytreatedoutsidethehospital.Normallyagallstoneattacklasts<24hoursandisnotaccompaniedbyfever.Thepatientissusceptibleforcholecystitisorcholangitisiffebrileorinpain>24hoursandshouldbeadmittedtothehospital.CholecystitisAninflammationofthegallbladder,mostoftencausedbyagallstoneobstructingtheoutletofthegallbladdersoitcan'tbeemptied.Thiscausesedema,inflammationandischemiaofthegallbladder.

SymptomsOPQRST:theonsetisoftensimilartoaregulargallstoneattack,butthepainispersistent.Thepainisdescribedasachingandconstant.Thepainisincreasedbymovementanddeepinspiration.Thepainisaccompaniedwithvomitingandfever.

ClinicalpresentationPatientacutelyaffectedbypain.Temperature37.5-38.5°C.Strongsorenesswhenpalpatingtherighthypochondriacregion.Sometimesthetensegallbladdercanbepalpatedduringinspiration;thisiscalledMurphy'ssign.Jaundicecanbeseen.

FurtherinvestigationsBloodsamples:↑CRPand↑leucocytes,↑bilirubincanbeseen,↑livermarkers(ALAT,ASAT,alkalinephosphatase)Ultrasoundofliverandbileducts.

DiagnosisMedicalhistory,clinicalfindingsandaprevioushistoryofgallstoneattacksshouldleadtosuspicionofcholecystitis.Ultrasoundconfirmsthediagnosis.Ifthepatientisseptic,suspectperforatedgallbladder!

TreatmentDuration<5days:preparethepatientforsurgery:laparoscopicremovalofthegallbladderthenextday.Duration≥5days:conservativetreatmentwithanalgesics,antibioticsandregularbloodsamplestomeasurethetreatmenteffect.Electiveremovalofthegallbladdercanbedoneafter3months.Ifthepatientisseverelyaffected,ultrasoundguidedgallbladderdrainageshouldbeconsidered.

ACUTEABDOMEN

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CholangitisCausedbyagallstoneortumorobstructingthecommonbileduct(ductuscholedochus;thebileductleadingthebiletotheduodenum).

SymptomsOPQRST:acuteonsetofpainintherighthypochondriacregion.Thepainissevereandconstantandaccompaniedbynausea.Oftenhighlyfebrilewithtemperature>39°C.Thepatientcanbeseptic.Oftenthepatientisknowntohavegallstonesoracancerinthebileduct.

ClinicalpresentationThepatientisacutelyaffected.Mostlikelywithjaundice.Strongpainwhenpalpatingtherighthypochondriacandepigastricregion,canbewithperitonealreaction.Vitalsigns:temperature39-40°C,tachycardia,lowbloodpressure(ifseptic).Cerebralinvolvementwithconfusioncanbeseen.

FurtherinvestigationsBloodsamples:↑CRPand↑leucocytes,↑↑↑bilirubin,↑livermarkers(ALAT,ASAT,alkalinephosphatase)UltrasoundoftheliverandbileductsMagneticresonancecholangiopancreatography(MRCP)

DiagnosisThemedicalhistory,clinicalfindingsandaprevioushistoryofgallstoneattacksshouldraisesuspicionofcholangitis.Findingssupportingthediagnosisareincreasedalkalinephosphataseandbilirubinaswellasotherlivermarkers.Dilatedcommonbileduct(>10mm)onMRCPorultrasonographyconfirmsthediagnosis.MRCPhasahighersensitivitythanultrasound.

TreatmentPreparethepatientforsurgery!Thetreatmentisendoscopicretrogradecholangio-pancreaticography(ERCP)andshouldbeperformedwithin24hours.ERCPisanendoscopicprocedurethatisusedtovisualizethebileductandextractthegallstonecausingtheobstruction.Astentcanbeplacedafterthestonehasbeenextracted.

ACUTEABDOMEN

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BowelobstructionAconditionwithpassagethroughtheintestineblockedbyanobstruction.Themostcommoncausesforbowelobstructionsarepreviousabdominalsurgery(causingadhesionsbetweentheintestinesandtheperitoneum),herniasandcancer.

SymptomsOPQRST:intermittentpainevolvingtoconstantpain.Paincanvaryfrommildtosevere.Symptomsvarydependingonthelocationoftheobstruction.Moreproximalobstructionswillquickerleadtovomitingthanmoredistalobstructions.Noflatulenceorexcretionoffecesfordays.

ClinicalpresentationDistendedabdomen,clinicaldehydration.Moredistalobstructionswillleadtomoredistension.High-pitchedbowelsoundscanbeheardwhenauscultatingthepatient.Ifperitonealreactionisfound,perforationshouldbeexpected.Rectalexplorationfortumorsshouldbeperformed.

FurtherinvestigationsBloodsamples:↑CRPand↑leucocytescanbeseen.Electrolytederangementcanbeseenaswell.ABGCT(ifpossiblewithcontrast)orX-rayoftheabdomen

DiagnosisCTorX-rayshowsdilatedintestinesandair-fluidlevels,confirmingthediagnosis.

TreatmentPreparethepatientforsurgery!Treatmentdependsofthecauseoftheobstructionandcanincludeexplorativelaparotomyorendoscopy.Thetreatmentshouldrelievethepatientoftheobstruction.

ACUTEABDOMEN

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AcutepancreatitisAnacuteinflammationofthepancreas.Theunderlyingcausesaremostoftenobstructionsofthebileductoralcohol,butmanyothercausescanbeseen.

SymptomsOPQRST:severeabdominalpainintheepigastricorlefthypochondriacregionradiatingtotheback.Nausea,vomiting,feverandperitonealreactioncausedbyileus(paralysisoftheintestines)canbeseen.Thepatientcanbeincirculatoryshockbecauseofhypovolemiaorsepsis.

ClinicalpresentationAcutelyaffectedpatientwithseverepain.Soreabdomen,possiblywithabdominalguarding.Vitalsigns:tachycardiaandhypotensioncanbeseen.Fever.

FurtherinvestigationsBloodsamples:↑↑↑amylase,↑CRP,↑leucocytesABGECGAbdominalX-rayorCT:toruleoutotherdiagnosesAbdominalultrasoundorCT:toseeifpancreasisenlargedoredematousorifanycystsortumorsarepresentChestX-ray

DiagnosisAbloodamylase3timeshigherthantheupperlimitofthereferenceintervalconfirmsthediagnosis.

TreatmentThetreatmentaimstoeliminatethecauseandtreatsymptomsandcomplications.Treatmentandsupportcaninclude:-Fluidsandelectrolytes(derangementsshouldbecorrected)-ERCPifthebileductisobstructed-Morphine-Nutritionaldiet-Protonpumpinhibitors-Considerantibiotics

ACUTEABDOMEN

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Urinarytractstones'Stones'areformedintherenalpelvis.Whenthestonespass,theycangetstuckintheureters,thebladderortheurethraandcausepainfulsymptoms.

SymptomsOPQRST:oftenwithoutsymptoms,butwhenobstructingtheuretertheycauseseverepainintheleftorrightlumbarregionwithsuddenonset.Thepainoftenradiatestothebackandgroinandtheintensitycanvary.Apatientwithurinarytractstoneswilloftenberestless.Symptomslastfrom30minutestoseveralhours.Nauseaandvomitingcanbeseen.

ClinicalpresentationAcutelyaffectedbypain,restless.Typicallysoreinthelumbarregion,butnotintherestoftheabdomen.Vitalsigns:nofever.Pain-inducedhypertensionandtachycardiacanbeseen.

FurtherinvestigationsBloodsamplestoruleoutotherconditions(resultsaretypicallynormal)UrinedipsticktestCT-urography

DiagnosisMedicalhistoryandclinicalfindingswithseverepain,butotherwisenotacutelyaffectedpatientgivesshouldraisethesuspicion..CT-urographyisdiagnosticwhenthestonecanbeseenintheurinarytract.

TreatmentRectalpainkillers.Anattacknormallydoesn'tlastformorethan6-8hoursifthestoneis<5mm,asthestonepassestheureterspontaneously.Hydronephrosis(enlargedrenalpelvis)shouldberuledoutandthepatientcanbedischargedwithpainkillers.Ifthestoneis>5mmortheobstructionhascausedhydronephrosis,thepatientshouldbeadmittedtoanurologicaldepartment.

ACUTEABDOMEN

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RupturedabdominalaorticaneurismAnaneurismisanabnormaldilatationofanartery.Theabdominalaneurismismorefrequentthanthethoracic.Theprevalenceofaneurismsincreaseswithage.Ananeurismisatriskofrupturing,whichcausesbleeding-thebiggertheaneurism,thebiggertheriskofrupture.Arupturedaorticaneurismisaconditionwithhighmortality.

SymptomsOPQRST:suddenonsetofseverepain,mostoftenintheumbilicalregion,radiatingtothebackandthighs.

ClinicalpresentationClinicalfindingsdependontheamountofbleeding.Thepatientpresentswithsignsofcirculatoryshock:paleandclammywithhypotensionandtachycardia.Apulsatingandsoreabdominalmasscanattimesbepalpatedbetweentheumbilicusandthexiphoidprocessofthesternum.

FurtherinvestigationsBloodsamplesincludingbloodtypeandbloodantigenscreening-testABGBedsideultrasoundcanshowaneurismandbleeding

DiagnosisTheclinicalpresentationofapatientincirculatoryshockshouldraisesuspicion.Inpatientsknownwithanabdominalaorticaneurism(previouslydiagnosedonultrasoundorCT),thediagnosisshouldbesuspected.

TreatmentPreparethepatientforimmediateemergencysurgery!Seekseniorandexperthelpimmediately.Orderblood(massivetransfusionpackaged–redbloodcells,freshfrozenplasmaandplatelets)andadminister.Plantransfertoavascularsurgicaldepartment.Surgerywithavascularprosthesisoranendovascularstenthastobeperformedasfastaspossible.

ACUTEABDOMEN

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GynecologiccausesoftheacuteabdomenInawomanpresentingwithacuteabdomen,alwaysconsidergynecologicalcauses.Onlyabriefoverviewofthemostimportantgynecologiccausestoconsiderisprovidedhere.Themostfrequentgynecologiccausesofacuteabdomenareectopicpregnancy,spontaneousabortionandovariancyststhatcanburstortorque.Allconditionscancausepaininthelowerabdomen.Ifthewomanisinthefertileage,alwaystakeapregnancytest(urineorplasmahCG)toruleoutectopicpregnancyorspontaneousabortion.Agynecologicexaminationshouldbeperformedtoruleouttumorsinthelowerpartoftheabdomenthatcouldbeanectopicpregnancyorovariancyst.Alwayspalpateforsoreness.Ifthepatientisnotacutelyaffected,atransvaginalultrasoundcanvisuallyinvestigateectopicpregnancy,cystsandbloodorfreefluidintheabdomen.Ifthepatientisacutelyaffected,surgerymaybeindicated.Gynecologiccausesofacuteabdomencancausebleedingintotheabdomen.Thiscanbealife-threateningconditionthatrequiressurgery.Torquedovariancystsshouldalsobetreatedwithemergencysurgerytopreventnecrosis.Aburstedovariancystisacommonandgenerallyharmlesscondition.Itcancausearelativelymildpainintheiliacregions,butwillnotacutelyaffectthepatient.Thepaintypicallydecreaseswithinacoupleofdays.FinalwordsAswritteninthebeginning,thisisapresentationofsomeofthepossiblecausesofacuteabdomenandisonlymeanttoprovideyouwithabriefoverview.Thedocumentisnotexhaustive,andyoushouldnotmemorizeeverything.Remember:Ifyouareindoubt,alwaysseekexperthelp–callaseniorcolleagueoraspecialist!